Voluntary Self-Identification Form

Vanderbilt University Medical Center is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.

Completing this form is voluntary but we hope you will choose to fill it out. Thank you for your cooperation

Section 1: General Employee Information

Name FirstLast

VUnetID (the ID you use to sign in to your computer and other Vanderbilt systems, e.g. doejane) *

Personal email (an email other than vanderbilt.edu)

Cellular Phone # *
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Yes, I would like to be included in Non Emergency emails.

Section 2: Please check all that apply

Race or Ethnic Identity *

Hispanic or LatinoWhite (not Hispanic or Latino)Black or African American (not Hispanic or Latino)Native Hawaiian or Pacific Islander (not Hispanic or Latino)Asian (not Hispanic or Latino)American Indian or Alaskan Native (not Hispanic or Latino)Two or more racesI do not wish to self-identify

Gender *

MaleFemaleI do not wish to self-identify

Married *

SingleMarriedDivorcedWidowedI do not wish to self-identify

Post-Hire Veteran Identification form

As a government contractor subject to VEVRAA, Vanderbilt University Medical Center is required to submit a report to the United States Department of Labor each year identifying the number of our employees belonging to each specified “protected veteran” category. If you believe you belong to any of the categories of protected veterans listed below, please indicate by checking the appropriate box below.

I BELONG TO THE FOLLOWING CLASSIFICATIONS OF PROTECTED VETERANS (CHOOSE ALL THAT APPLY):

DISABLED VETERANRECENTLY SEPARATED VETERANACTIVE WARTIME OR CAMPAIGN BADGE VETERANARMED FORCES SERVICE MEDAL VETERANI am a protected veteran, but I choose not to self-identify the classifications to which I belong.I am NOT a protected veteran.I decline self-identification

If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are consistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended.

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 1 of 2

Why are you being asked to complete this question around disability?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.* To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used
against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

YES, I HAVE A DISABILITY (or previously had a disability) NO, I DON’T HAVE A DISABILITYI DON’T WISH TO ANSWER

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
Page 2 of 2

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

*Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

**These next two questions are voluntary and are not required by the Federal Government and will not be maintained in your permanent HR record***

Gender Identity

MaleFemaleTransgenderI do not wish to self-identify

Sexual Orientation

Heterosexual or straightGay or LesbianBisexualOtherI do not wish to self-identify